Part III. Information about Funded Status of Plan

As required by § 104(b)(2) and (4) of ERISA, the plan administrator must furnish a copy of the latest annual plan report upon written request and make the annual report available for inspection at its principal office, which is located at [INSERT ADDRESS]. Under § 101(k)(1) of ERISA, any application for an extension of the amortization period under § 304(d) of ERISA or § 431(d) of the Code (including the application for extension described in this notice) and the determination made by the IRS with respect to such application may be obtained upon request by writing to the plan administrator at the above address. Such documents must be furnished by the plan administrator no later than 30 days after receipt of the written request. Section 502(c)(4) of ERISA grants the Department of Labor the authority to assess civil penalties not to exceed $1,000 per day for each violation of § 101(k).

[Instruction: If the plan administrator makes a reasonable charge to cover copying, mailing, and other costs of furnishing copies permitted under § 101(k) of ERISA, the amount of such charge should be stated in the notice.]

In accordance with § 104 of ERISA, annual financial reports for this plan, which include employer contributions made to the plan for any plan year, are available for inspection at the Department of Labor in Washington, D.C. Copies of such reports may be obtained upon request and upon payment of copying costs from the following address:

Public Disclosure Room Room N–1513 Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, D.C. 20210

For 2009 and subsequent plan years, you may obtain an electronic copy of the plan’s annual report at www.efast.dol.gov and accessing the Form 5500 search function.

The following information is provided pursuant to § 304(d)(3) of ERISA and § 431(d)(3) of the Code:

Present value of accrued benefits $

Present value of benefits that are guaranteed by the PBGC, calculated as though the plan terminated $

Fair market value of plan assets $

The above calculations were as of [INSERT DATE]. The above present values were calculated using an interest rate or rates of [INSERT INTEREST RATE(S)].

[SIGNATURE OF AUTHORIZED TRUSTEE OF THE APPLICANT BOARD]

[INSERT NAME]

[INSERT TITLE]

December 27, 2010 933 2010–52 I.R.B.